Practice Question
A community health nurse is triaging clients following a worksite explosion.
Answer Choices:
Correct Answer:
Client 4
Rationale:
💎 Client 4 — Severe head and cervical spine injury The client is unconscious with fixed pupils and later exhibits decorticate posturing and irregular, shallow respirations, all of which indicate increased intracranial pressure (ICP) and brainstem involvement.
💎These are life-threatening neurologic and respiratory findings requiring immediate stabilization of airway and cervical spine.
💎Priority actions: Maintain airway, provide oxygen, prepare for possible intubation, and immobilize cervical spine.
💎This client is a Red Tag (Immediate) priority under disaster triage principles.
💎 Client 6 — Smoke inhalation injury
💎Initially stable, but now has diminished breath sounds, intercostal retractions, tripod position, and anxiety, showing impending airway obstruction from inhalation injury or edema.
💎Rapid deterioration of oxygenation and ventilation makes this client a critical airway emergency.
💎Priority actions: Secure airway, administer high-flow oxygen, prepare for intubation before respiratory failure occurs.
Also classified as Red Tag (Immediate).
💎Client 2: Pain and mild hypotension from burns (Yellow Tag – Delayed).
💎Client 1: Minor laceration (Green Tag – Minimal).
💎Client 3: Stable head contusion, alert (Green Tag – Minimal).
💎Client 5: Open fracture with stable circulation (Yellow Tag – Delayed).
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This question is from RN Community Health 2023 (2025) which contains 58 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Community Health
- Answer Choices: 6